2. Chapter 4 Aging, Health, and Long-Term Care

3. Objectives After studying this chapter the student should be able to: List at least three benefits for the elderly provided by Medicaid that are not provided by Medicare. Differentiate between skilled nursing and intermediate care facilities. Describe the services provided by assisted living facilities. Describe the services provided by each of the following: (a) home health, (b) hospice, and (c) shelter care homes and workshops. Discuss the role of health literacy in delivering quality health care. Explain how shifts in demographics will impact the skills and training needs of healthcare workers. Discuss future trends in long-term health care including community- based care.

4. The Impact of Future Changes on Healthcare Needs As the population of people over 65 yo increases, increases, more services will be required for the treatment and management of chronic and acute health conditions and disabilities. Those on Medicare with multiple chronic conditions, especially the frail elderly with functional or cognitive impairments, in addition to chronic medical illness, will need care coordination

5. U.S. Census Bureau Projections By 2050 due to increase in life expectancy: –people 65 and older will represent 20% of the total U.S. population –Those that are 85 and older (the “old-old”) are the fastest growing segment of the population 61% are women (mostly widows) The “old-old” are expected to account for 19 million

6. The Future “Chronic diseases, arising from both emotional and physical causes, will be the most important of the future disabilities”

7. Common Health Problems in an Aging Population The most prevalent chronic conditions in 2007 among the elderly were, in order of prevalence: Hypertension (high blood pressure) Arthritis Heart disease Cancer Diabetes Update 2014 (CMS) that hypertension, high cholesterol, heart disease, arthritis and diabetes are the most prevalent Depression was one of the top 7

8. Common Health Problems in an Aging Population Limitations associated with aging increase dramatically after age 85 years: Hearing impairment (60%) Visual impairment (28%) The most debilitating conditions: Dementia (accounts for almost half of nursing home residents) Stroke Hip fractures

9. Medicare for the Elderly Medicare is divided into four parts: Part A - hospital insurance; all elderly beneficiaries are automatically enrolled. Part B - supplemental medical insurance, voluntary; the majority of the elderly purchase –does not provide dental, vision, podiatry or routine physical exams. Part C – “Medicare advantage”; private supplemental hospital and medical insurance Part D - medication insurance

10. Medicaid for the Elderly Medicaid covers a broad range of services not covered by Medicare, acting as a supplemental insurance for the elderly and disabled. It also pays their Medicare premiums; includes cost-sharing (out of pockets costs) and covers prescription drugs. A large number of the elderly do not take advantage of Medicaid because of the inability to navigate the system.

11. Long-term Care Insurance Long-term health care (LTC) - the help needed by people of any age who are unable to care for themselves because of physical and/or mental impairment; almost as many impaired young adults and children need LTC as the elderly (4 vs. 6 billion) LTC is for extended periods, ranging from months to years to a lifetime. LTC is provided in nursing homes (70%), institutions, rehab hospitals, the community, or it can be home based.

12. Nursing Homes There are two types of recognized homes: Skilled Nursing Facility (SNF) Intermediate Care Facility (ICF) The federal government, through CMS, is responsible for nursing home standards Individual states – responsible for monitoring facilities to ensure standards are being met.

13. Nursing Homes A skilled nursing facility (SNF) is a nursing home that provides the level of care closest to hospital care: Twenty-four-hour nursing services, medical supervision, rehabilitation, physical therapy, pharmacy and dietetic services, and occupational and recreational therapy are provided in accordance with federal guidelines. Skilled homes are for convalescents (someone recovering from an illness or operation) and patients with long-term illnesses.

14. Nursing Homes An intermediate care facility (ICF) provides less extensive care and services: –For people that need daily personal care because they are not able to care for themselves or live alone, but they do not need 24-hour care. –the emphasis is on personal care and social services. –Some also employ rehabilitation and occupational therapists. –These homes must meet federal guidelines to receive government funding.

15. Assisted Living Care Facilities Facilities dedicated to providing assistance with activities of daily living – dressing, bathing, eating, using the bathroom May be part of a retirement community, nursing home, senior housing or a stand-alone facility Residents or the families typically pay the cost, but Medicaid finances care for about 12%

16. Nursing Home Regulation An act named OBRA 87 created minimum standards of care for nursing homes in response to concerns about poor quality of care and inadequate regulation; including staffing requirements and rights (p. 47) for residents –standards emphasized quality of life issues and the prevention of abuse, mistreatment, and neglect, including the use of physical and chemical restraints.

17. Community Services The Program of All-Inclusive Care for the Elderly (PACE) provides comprehensive preventive, primary, acute, and long-term care services for older individuals with chronic care needs Eligibility: 55 years or older and certified by their state to need nursing home care but don’t need to live in a facility PACE receives Medicare and Medicaid capitation payments

18. Community Health Agencies Home Health Agencies (HHAs) provide part- time nursing and medical care in patients’ homes –other services: physical, speech, and occupational therapy; social services; some medical supplies and equipment, i.e. wheelchairs, walkers, etc. Meals on Wheels (an HHA variation) - agency that supplies one hot meal a day (usually lunch) to people who are confined indoors due to a mental or physical disability

19. Hospice Hospices care for individuals that are dying. Hospice care helps manage pain and other symptoms associated with dying when conventional treatment is no longer of value Hospices are operated on the principle that the dying have special needs and wants that hospital personnel are too busy to handle. This care improves the quality of the remaining time in ones’ life.

20. Supportive Housing The U.S. Department of Housing and Urban Development provides supportive housing/shelters for the homeless with disabilities, primarily those with severe mental illness, or chronic problems with alcohol or drug abuse (don’t need nursing home care) Federal regulations on operations, i.e. diet, sanitation Both shelter care homes and sheltered workshops are available to long-term care recipients –workshops are where those with physical or mental challenges can learn a skill

21. Demographic Trends and Projections By the mid-twenty-first century, the number of elderly individuals will triple. Racial and ethnic minority groups will continue to increase  we must take a varied approach to meet their health needs (cultural competence) as these differ from white individuals The need for LTC (home and nursing home care) and the associated costs will increase tenfold.

22. Potential Healthcare Needs Interesting to note that more than 90% of elderly people continue to live in the community, and more than two-thirds of them perceive their health to be good to excellent. The authors of the book believe that in the future, the majority of older individuals are likely to be healthy and able to function independently (what do you think?)

23. Health Service Needs for the Elderly Necessary services include prevention, as well as primary, acute, post-acute, rehabilitative, long- term, and hospice care. Because the “old-old” population is increasing most rapidly  services need to focus on maintaining the functional capacities and on providing long-term care to the frail elderly. There will also be an expansion in people aged 65 and older  need more preventive, primary, and acute care services.

24. Personnel Needs We will soon need more personnel specifically prepared to serve older people Greatly expanded training programs are required to prepare personnel to provide services in homes, hospices, nursing homes, and other community settings. To provide responsive care to older persons, greater emphasis on the special needs and conditions of older persons (geriatrics) should be included in the education of all health and human service personnel.

25. Future Education for the Health Professions We are currently NOT prepared for the projected increase in elder Americans! Curricula must include the requirements and care of the elderly population. We also need to assume an active role in developing acceptable health policies. Health professionals must be able to assess needs accurately and teach at all levels.

26. Shifts in Training Health Personnel Need to develop a broader understanding and competence in geriatrics. Physicians direct the work of other health personnel, and therefore will need to develop additional competencies and leadership roles for the practice of geriatric medicine. Nurses, Dentists, dental hygienists, and dental assistants will be serving substantially larger numbers of elderly and their education should now reflect this. Social work personnel must be prepared to meet the diverse social services needs of the elderly. They will require a specialized knowledge of the aging process and the interpersonal dynamics of the aging and their families.